Provider Demographics
NPI:1144680240
Name:JACKSON MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:JACKSON MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-324-8469
Mailing Address - Street 1:1200 S JACKSON ST
Mailing Address - Street 2:SUITE 27
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2026
Mailing Address - Country:US
Mailing Address - Phone:206-324-8469
Mailing Address - Fax:
Practice Address - Street 1:1200 S JACKSON ST
Practice Address - Street 2:SUITE 27
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2026
Practice Address - Country:US
Practice Address - Phone:206-324-8469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1032648Medicaid
WA1032648Medicaid
WA000106841Medicare PIN